Guideline panellists have differing opinions on whether resource use should influence decisions on individual patients. As medical care costs rise, resource use considerations become more compelling, but panellists may find dealing with such considerations challenging

In this last part of a series describing the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to making recommendations we will look at how guideline panellists and clinicians can incorporate matters related to the use of resources into recommendations and practice. Clinical recommendations inevitably involve judgments about the allocation of resources, judgments commonly referred to as costs. We will deal with some of the challenges of considering costs, explain reasons for focusing on resource use rather than costs, and discuss how to incorporate considerations of resource use into recommendations.

Cost as an outcome presents special challenges

In one sense, cost is just another potentially important outcome—like mortality, morbidity, and quality of life—associated with alternative ways of managing patients. In addition to these clinical outcomes, an intervention may increase costs or decrease costs. However, costs differ from other outcomes in several ways (box).1

In what way do costs differ from other health outcomes?

Patients receive health benefits and bear the burden of adverse health outcomes, but healthcare costs are typically shared by society as a whole (as represented by the government), employers, and patients

Attitudes differ as to whether costs should influence a doctor’s decision about treating individual patients

Healthcare costs may vary widely among and even within jurisdictions and quickly change over time

What societies can purchase if they forego use of healthcare resources (opportunity cost) varies widely between countries. A year’s supply of an expensive drug may pay a nurse’s salary in the US and 30 nurses’ salaries in China

When healthcare expenditures demand foregoing expenditures elsewhere, attitudes differ as to whether the health system, public expenditures, or society as a whole should bear the burden

Matters relating …

Get access to this article and to all of thebmj.com for 14 daysSign up today for a 14 day free trial